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Publisher: The Partnership for Maternal, Newborn and Child HealthPublication date: 2013Language: English only

Investing in women’s and children’s health will secure substantial health, social and
economic returns. Increasing health expenditure by only US$ 5 per capita per year until 2035
(equivalent to US$ 30 billion per year, and in per capita terms representing a 2% increase in
current spending) in the 74 high-burden countries could result in up to nine times that value in
economic and social benefits. These benefits include greater GDP growth through improved
productivity, as well as avoiding the preventable deaths of 147 million children, 32 million stillbirths,
and 5 million women between 2013- 2035.

The challenge

Despite a significant reduction in maternal and child
mortality over the last two decades (Maternal
Mortality Rate (MMR) reduced by 47% from 1990-2010;
Under-five Mortality Rate (U5MR) by 47% from 1990-2012),
the progress is not sufficient to achieve Millennium
Development Goals 4 and 5. 1,2The investment gaps, which
lead to high rates of preventable maternal and child deaths,
are well known: insufficiently resourced health systems with
low levels of coverage of essential interventions, and poor
health information and management systems making
inefficient use of limited resources.

The leading causes of maternal mortality – obstetric
haemorrhage, hypertensive disorders of pregnancy, sepsis
and unsafe abortion – are largely preventable with well equipped
health facilities, presence of skilled care
providers, a functioning referral system, and reliable
supplies of life-saving commodities. However, access to
services to prevent these deaths remains low, especially
among the poorest in high-burden countries. 3 Similarly,
17% of deaths among children under five are due to
diseases that can be prevented by routine, cost-effective
vaccination (e.g. pneumonia and diarrhea).4,5 Vaccination
coverage to prevent these conditions could be scaled up by
strengthening supply chains, training health workers, and
outreach activities to rural communities. High malnutrition
rates are an important factor in maternal mortality, and
contribute to over 45% of all under-five deaths, as well as
impacting later years of life.6,7

Poor health service coverage leads to significant economic
and social consequences, especially for poor and vulnerable
groups. 8,9 For example, unexpected healthcare costs are a
leading cause of impoverishment in many countries. 10

What do we know?

Summary of knowledge base

The Global Investment Framework (GIF) builds on
previous investment frameworks by estimating the
effects of investment on RMNCH across the continuum of
care, including family planning, stillbirths and newborn
health.11 It also extends the analysis of economic and social returns on investment to 2035 to provide an updated estimate of the health, social and economic benefits of
investing in health systems strengthening to deliver
RMNCH interventions. The focus is on 74 low- and
middle-income countries that account for more than 95%
of maternal and child deaths.

Conceptual framework for estimating the economic and societal benefits of improved health

The conceptual framework that underpins the GIF (Figure 1)
starts with the overall health and development context,
and identifies four ‘key enablers’ that drive health outcomes
on policy, health system, community engagement, and
innovation. It then defines a package of evidence-based
RMNCH interventions with health benefits for women and
children, recognizing the importance of the ‘first thousand
days’ (from conception to two years after birth).12 The
framework outlines the costs associated with these ‘key
enablers’ and the critical interventions, and estimates gains
in terms of ‘lives saved’ and ‘healthy lives’, in addition to
societal gains.

Calculation of returns on investment

Approach

The GIF, focusing on interventions where data on
effectiveness is available, estimates the cost and impact of
delivering six packages of interventions (Box 1) provided at
four delivery points: hospital, first level facility, outreach
and the community. Nutrition is a crosscutting theme.

Each package includes costs for inpatient and outpatient
care and the supply of commodities. Cost estimates are
also included for managing RMNCH programmes,
improving accessibility to health services for adolescents,
and using conditional cash transfers to encourage women
to give birth in health facilities. Broader health system
strengthening costs are also captured, such as for
improving infrastructure (frontloaded investments),
governance, supply chains, information systems and
implementing a health financing policy.

Three scenarios are used to estimate the incremental cost
and impact of varying the levels of coverage for the
investment packages in the 74 high-burden countries:

Low scenario – assumes coverage is maintained at
current levels (considered as the counterfactual).

Medium scenario – assumes scale-up according to
available historic trends for coverage in each country
between 1990-2010.

High scenario – a more ambitious scenario where
scaling-up coverage is based on accelerating current
trends using a ‘best performer’ approach.

Cost estimates are based on an ‘ingredients approach’
where needs-based quantities are multiplied with countryspecific
prices/ service delivery costs. Sensitivity analysis
was also undertaken on cost estimates (e.g. for the
allocation of health systems costs to RMNCH, and for
commodity and service delivery costs).

Investment requirements

The additional investment required for the high coverage
scenario as compared to the low scenario equates to an
average of US$ 5 per capita per year from 2013 to 2035
across the high-burden countries (as compared to the medium
scenario which would require US$ 3). In absolute terms,
this additional investment reaches around US$ 30 billion
per year in year 2035. Figure 2 illustrates the cost profile of
this additional investment by category.

Health impact of additional investments

Additional investments to increase and improve the
coverage of essential RMNCH interventions would
significantly reduce maternal and child mortality in the 74
high-burden countries. In particular, the high investment
scenario would result in 147 million fewer child deaths, 32
million fewer stillbirths, five million fewer maternal deaths,
and a reduction in the total fertility rate from 2.7 to 2.0
between 2013-2035.13,14 Along with a reduced number of
unintended pregnancies and improved nutrition status of
children, additional investment would also result in a
significantly higher quality of life for millions who not only
escaped death, but also lifelong disability.

Economic and social returns

The expected economic and social benefits from improving
the coverage of essential RMNCH interventions are
significant. Under the high scenario, an additional average
investment of US$ 5 per capita per year from 2013 to 2035
would result in up to nine times that value in economic and
social benefits for the 74 high-burden countries. The
economic benefits arise from increased labour force
participation and productivity which results from reduced
mortality and morbidity, as well as higher per capita incomes
arising from lower incidence of unintended pregnancies.
Social benefits capture the social value of a human life —
i.e. the value placed by communities on women, mothers,
children, and families being healthy – as a percentage of GDP.

The social benefits of investment start accruing almost immediately, whereas the economic benefits take time to
build up. Total benefits, measured as the sum total of
mortality reduction, morbidity aversion and demographic
dividend, exceed total costs (which require some
frontloading, e.g. to support health systems strengthening
and infrastructure costs) by 2017, and continue to
increase rapidly beyond that year.

Conclusion

Investing in women’s and children’s health saves
millions of lives and could yield significant health,
social and economic returns, potentially up to nine times
the value of the investment. On average, this could be
achieved by making an incremental investment of US$ 5
per capita in the 74 low- and middle- income countries
till 2035. This investment is estimated to save a total of
five million maternal deaths, 147 million child deaths, and
32 million stillbirths between 2013 and 2035.

References

1. WHO, UNICEF, UNFPA, World Bank. Trends in maternal mortality: 1990
to 2010. WHO, UNICEF, UNFPA and The World Bank estimates. 2012.
2. UNICEF, WHO, World Bank, UN DESA/Population Division. Levels and
Trends in Child Mortality Report 2013. Estimates Developed by the UN
Inter-agency Group for Child Mortality Estimation.
3. WHO, UNICEF. Countdown to 2015. Accountability for maternal, newborn
and child survival: The 2013 Update.
4. WHO Immunization surveillance, assessment and monitoring: vaccine
preventable diseases. http://www.who.int/immunization_monitoring/diseases/en/
(accessed Nov 6, 2013).
5. Walker CL, Rudan I, Liu L, et al. Global burden of childhood pneumonia and
diarrhoea. Lancet 2013; 381: 1405–16.
6. Bhutta ZA, Das JK, Rizvi A, et al, The Lancet Nutrition Interventions Review
Group and the Maternal and Child Nutrition Study Group. Evidence-based
interventions for improvement of maternal and child nutrition: what can be
done and at what cost? Lancet 2013, 382(9890):452-77.
7. Black RE, Victora CG, Walker SP, and the Maternal and Child Nutrition Study
Group. Maternal and child undernutrition and overweight in low-income and
middle-income countries. Lancet 2013: 382(9890):427-51.
8. Victora CG, Barros AJD, Axelson H, et al. Equity in coverage of maternal and
child health interventions in 35 Countdown to 2015 countries: analysis of
national surveys. Lancet 2012; 380: 1149-56.
9. Barros AJ, Ronsmans C, Axelson H, et al. Equity in maternal, newborn and
child interventions in Countdown to 2015: which are the most inequitable
countries and interventions? Lancet 2012; 379: 1225-33.
10. Xu K, Evans DB, Kawabata K et al. Household catastrophic health
expenditure: a multicountry analysis. Lancet 2003; 362, 111-17.
11. Previous investment frameworks include an investment framework for HIV/
AIDS, investment cases for RMNCH (including the PMNCH-coordinated
investment case for Asia and the Pacific and for health systems
strengthening in Africa), and the WHO EMRO case for investing in
scaling up interventions in the region.
12. PMNCH, WHO, Aga Khan University. Essential interventions,
commodities and guidelines: A global review of key interventions
related to reproductive, maternal, newborn and child health.
13. The impact analysis is based on epidemiological models included within the
OneHealth Tool, in particular the Lives Saved Tool (LiST), which estimates
reduction in mortality rates based on modelled increases in coverage.
14. The estimated number of deaths prevented is based on a comparison
between outcomes in the high scenario with a lower population growth, to
those in the low scenario with a growing population. As such, the number of
deaths averted in 2035 is greater than current estimated number of deaths.

Acknowledgements

Developed by Cambridge Economic Policy Associates (CEPA) based on the Lancet Article, published on 19 November 2013, with the same title, and key references
included in this summary with contributions from the PMNCH Secretariat and WHO. Design by Roberta Annovi.

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